The patient is a (XX)-year-old female with known coronary artery disease who presented to the cardiology clinic with complaints of increasing intensity and frequency of chest pain. The patient is status post coronary artery bypass grafting in the past. Secondary to this, the patient was referred for left heart catheterization.

PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the cardiac catheterization laboratory and prepped and draped in usual sterile fashion. The right femoral artery was anesthetized and accessed via the Seldinger technique. Catheters used for the procedure were Judkins left #4, Judkins right #4, pigtail catheter and a Judkins right #4 guide catheter.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Less than 10 mL.

HEMODYNAMICS: The patient's aortic pressure was 130/70 with left ventricular pressure of 130/5 and left ventricular end diastolic pressure of 20. There was no gradient upon pullback of the pigtail catheter.

CORONARY ARTERIES:

1. Left main coronary artery is angiographically normal.

2. Left anterior descending was a small sized vessel. The left anterior descending had mild to moderate luminal irregularities, but no significant stenosis. There was distal thinning and a 40% stenosis noted in the distal left anterior descending. The first diagonal branch did have a subtotal occlusion. The distal portion of the first diagonal branch was filling with competitive flow.

3. Left circumflex was a small vessel and was noted to have a 60% proximal stenosis and a 70% to 80% mid/distal stenosis. This was a very small vessel and 2 mm in diameter. There was a second obtuse marginal branch, which was 100% occluded.

4. Right coronary artery dominant with stents noted in the ostial and proximal portion. There was an ostial 90% to 95% stenosis noted within the stents. There was no competitive flow noted in the distal vessel.

Saphenous vein graft to the first diagonal branch and then skipped to the second obtuse marginal branch was injected. The ostium body and touchdown site of the graft was free of significant disease. There was mild to moderate luminal irregularities noted in the diagonal branch itself. There was a mid 40% to 50% stenosis in the diagonal branch after the touchdown site. There were mild luminal irregularities noted in the second obtuse marginal branch itself.

Right internal mammary artery was injected. The ostium body and touchdown site of the right internal mammary artery to the distal posterior descending artery was intact. There was very faint backfilling of the posterolateral branch. There was a lot of competitive flow noted from the native vessel. There was no significant disease noted in the posterior descending artery.

Left ventriculogram was performed in the RAO projection, which showed normal left ventricular systolic function with ejection fraction 60%. There were no wall motion abnormalities. There was no gradient upon pullback of pigtail catheter. There was no noted mitral regurgitation.

After diagnostic cardiac catheterization was performed, the 5 French sheath was exchanged for a 6 French sheath. Heparin and Integrilin were given. We decided to go after the right coronary lesion. We did not feel like the right internal mammary artery was giving sufficient flow to the large dominant right coronary artery. Secondary to this, we used a Judkins right #4 guide catheter to insert into the ostium of the right coronary artery. Guide shots were obtained, which confirmed the 95% stenosis in the ostial right coronary artery which was in-stent. We used a BMW wire to cross the lesion. Predilation was done with a Monorail Maverick 3.0 x 9 mm balloon. This was taken up to 20 atmospheres for 15 seconds. This resulted in 40% residual stenosis in that area. We then stented using a Cypher 3.5 x 18 mm drug-eluting stent in the ostial and proximal portion of the right coronary artery. This was taken up to 25 atmospheres for 15 seconds. We then postdilated at the ostium with a 3.75 x 8 mm Quantum balloon taken up to 20 atmospheres for 15 seconds. This resulted in 0% residual stenosis. There was good flaring of the ostium of the right coronary artery. There was good flow noted in the right coronary artery and no residual stenosis noted.

IMPRESSION:

1. Severe three-vessel coronary artery disease.

2. Small left circumflex with significant stenosis noted in the mid/distal portion. This was a small vessel at that area.

3. Patent saphenous vein graft to the first diagonal and skip to the second obtuse marginal branch.

4. Patent right internal mammary artery to distal posterior descending artery. This was a small vessel. No good backfills of the posterolateral branch.

7. Successful angioplasty and stenting of the ostial/proximal dominant right coronary artery with the Cypher drug-eluting stent resulting in 0% residual stenosis.

PLAN: The patient will continue on Integrilin overnight and will continue on aspirin and Plavix. We will load her on Plavix today and continue her on 75 mg daily. The patient needs aggressive medical management. The patient will follow up in cardiology clinic in 1 to 2 weeks for further evaluation and treatment.

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All personal information, including patient and physician names/dates/location, etc., has been deleted or changed, in order to maintain the highest professional standards of patient/physician confidentiality. Also, do note that the sample reports found on this site vary in terms of formats, depending on account specifics of various clients, and are part of this blog for informational and educational purposes only, and not intended to replace professional medical advice or opinions from qualified, licensed physicians.